A subcutaneous implantable cardioverter-defibrillator — the first implantation in Poland

Abstract

We present the case of a 28-year-old patient successfully implanted with a subcutaneous implantable cardioverter-defibrillator (S-ICD) in secondary prevention of sudden cardiac death. The patient was resuscitated from out-of-hospital cardiac arrest due to ventricular fibrillation (VF). This was complicated by pneumothorax and respiratory failure that required mechanical ventilation for 5 days. After 2 weeks on the intensive care unit, the patient was transferred to the Cardiology Department. A subsequent medical evaluation revealed no structural heart abnormalities, nor other overt cardiovascular dysfunctions. However, during an invasive electrophysiological study, VF was induced with programmed right ventricular stimulation (Fig. 1). Therefore, the patient was implanted with an ICD. One week after this procedure, he presented symptoms of fever, shivers and chest pain. A fulminant endocarditis and right ventricle perforation was diagnosed. Subsequently, an adequate intravenous antibiotic treatment was introduced and the ICD system was explanted. Nevertheless, the important destruction of the tricuspid valve was revealed in echocardiography, and cardiothoracic surgery with artificial tricuspid valve replacement (Medtronic 29 mm) was performed. The surgery was complicated by intermittent complete atrio-ventricular block, thus the epicardial lead was implanted to the left ventricle and connected to the pacemaker placed in the right subclavian region. After 3 weeks of in-hospital recovery, the patient was consulted by an international board of arrhythmology specialists in order to establish the possibility of S-ICD implantation. The electrocardiography screening to check S-ICD arrhythmia discriminators matching with sensed cardiac signals was completed successfully, as well on the intrinsic rhythm as during pacing. Eventually, the patient was referred to S-ICD implantation. The procedure was performed on oral anticoagulation with acenocoumarol (INR on the day of procedure was 2.1), in volatile and maintenance anaesthesia by a joint team of cardiologist and cardiothoracic surgeon. The S-ICD was positioned in the left lateral region between the 5 th and 7 th intercostal spaces. The subcutaneous defibrillation lead was implanted atypically -in parasternal instead of medial line. The reason for atypical positioning of the lead was to avoid collision with the epicardial lead that had been previously implanted in the substernal region and to avert complications in case of future medial resternotomy. The position of the device and the lead is presented in Figure 2. Considering the high thromboembolic risk, testing of the defibrillator was successfully performed after transoesophageal echocardiography on the 4 th day after the implantation. The post-procedure course was uneventful. We present the first Polish experience of implantation of a S-ICD system. This modern therapy is an option for those patients who cannot have a standard ICD implanted for any reason, e.g. vascular abnormalities or intravascular infection. This pro...

Evolution of implantation technique and indications for a subcutaneous cardioverter-defibrillator: over 7 years of experience in Poland

“…Implantation of a subcutaneous cardioverter-defibrillator (S-ICD) may be used to prevent sudden cardiac death (SCD) due to ventricular arrhythmias in patients not requiring permanent cardiac pacing or antitachycardia pacing [1,2]. That method of treatment was first applied in Poland in 2014 [3,4]. But it took the S-ICD implantation procedure several years to become in 2019 reimbursed to the extent sufficient to cover the whole cost borne by the implanting centers.…”

Utilization of Subcutaneous Cardioverter-Defibrillator in Poland and Europe–Comparison of the Results of Multi-Center Registries

“…According to the European and American guidelines, S-ICD is contraindicated if a patient requires permanent cardiac pacing, including resynchronization therapy, or has a history of ventricular tachycardia that is possibly eligible for termination with antitachycardia pacing [ 3 , 4 ]. S-ICD systems have been used in Poland since 2014 [ 5 , 6 ]. Due to complex rules of reimbursement, the number of procedures was initially low.…”

Multicentre early experience with totally subcutaneous cardioverter-defibrillators in Poland

“…The first S-ICD implantation in Poland was performed in October 2014 in a young male adult who had an T-ICD removed and an artificial tricuspid valve implanted due to fulminant endocarditis [8].…”